State officials are hoping to revive a short-lived community paramedicine program to prevent unnecessary 911 calls and reduce health care expenditures.
The Senate Ways and Means Committee passed Senate Bill 2374 on Friday. The measure appropriates $1.5 million to establish a three-year pilot program targeting high-risk, frequent 911 callers, many of whom are homeless, to connect them with primary care or mental health services. The bill still must be approved by the Legislature.
Frequent callers often use emergency services for chronic diseases, which could be better managed in a doctor’s office, or may be living in rural communities where it’s difficult to access services.
At the Queen’s Medical Center, which sees most of Oahu’s high-volume users, there are more than 600 unnecessary ambulance visits during an average three-month period. Those visits result in costs of more than $600,000 quarterly, or $2.4 million annually, according to a December 2016 legislative report. More than 1,500 Queen’s emergency room visits and annual costs of more than $12 million are attributed to frequent callers with non-emergencies.
“This population is totally overwhelming the ERs,” said Dr. Jim Ireland, former head of Honolulu Emergency Medical Services. “They’re mostly on Medicaid and that’s a state insurance cost, so it’s all getting passed onto the taxpayers.”
Community paramedicine, which refers to paramedics in non-traditional roles, is designed to target the specific medical needs of different communities. That includes increasing access to health care in rural areas, as well as reducing hospital readmissions.
Jesse Ebersole, EMS captain and one of two community paramedics for the Hawaii Fire Department, said the duo has made about 260 unscheduled visits across the island since the start of a pilot project in October 2016.
One such visit in January involved an elderly man who was living off the grid in a rat-infested home in Puna with no running water or electricity and little food. The man, who was in his 60s, had previously been referred to adult protective services because of his “horrendous” living situation. But he didn’t want to leave the home until Ebersole, accompanied by a resident physician, convinced him to seek help.
“It was probably one of the worst living conditions that I had seen. We were referred to the case kind of in desperation because nothing was happening,” he said. “Basically we offered him a way out. We tried to help him see what we were seeing and let him know he deserved and needed to be in a safer environment where he could be healthy and safe and be able to see his children and his grandchildren.”
The next day, the man was placed in a long-term residential care home.
“We’re making unscheduled proactive visits to people who are in vulnerable situations trying to connect them with services already existing in the community,” Ebersole said. “Managing an individual chronic disease is difficult enough, combine that with depression or anxiety, coupled with geographic or social isolation, transportation issues, financial strain, lack of social support and the situation becomes overwhelming to handle. During a medical crisis, these individuals often call 911, EMS becomes their safety net.”
The proposed pilot project intended for Oahu and a neighbor island would likely include three to four full-time paramedics in each location helping a minimum of one patient per hour, or eight people a day. The paramedics would help them to manage their medicines and chronic diseases, as well as prevent injuries or follow up with them after they’re discharged from the hospital, said Dr. Alvin Bronstein, chief of DOH Emergency Medical Services Injury prevention Systems Branch.
“It points to the fact that a functioning community paramedic program can help to reduce a lot of the pressure and burden on our EMS system right now,” said Sen. Jill Tokuda (D, Kaneohe), who introduced the bill. “In some cases it’s not that these individuals need an ER room, they need access to different kinds of care but they feel like it’s their only option.”
The proposed legislation also earmarks $250,000 to start a training program for community paramedics.
“Based on some of the successes and lessons learned from other similarly aimed programs on the mainland we strongly feel that our pilot will show significant reductions in EMS utilization from our top users,” said Chris Sloman, Honolulu EMS assistant chief of operations. “Hopefully this will improve their health and quality of life. We expect this will also result in substantial cost savings not only to EMS, but by reducing the number of unnecessary hospital emergency department visits, it will have a cascading effect on hospitals and coverage providers.”
The city tried to address the issue in 2012 when it created a community paramedicine pilot project, which ended due to inadequate funding.
At the time, Honolulu EMS deployed community paramedics to reach out to the top 50 callers who on average make 1,600 calls a year to 911. They connected with the “hyperusers” once a week at home, at shelters or in parks to guide them to social and medical support. In 2012, the direct cost for the top 50 callers was estimated at $2.6 million, not including hospitalizations.
The top five people transported by ambulance last year called 54 to 194 times, according to EMS. All but one was homeless. An ambulance ride alone costs about $1,127 and emergency room charges can range from $1,000 to $5,000 depending what tests are run. That puts the cost of a non-emergency transport for the top caller at $218,638 a year.
“The bottom line is we want people to get better and more appropriate care and at the same time save money and resources,” Ireland said. “It just doesn’t make sense for people to use an ambulance 100 times a year and get seen in the emergency room.”